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Documenti di Professioni
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AMELIA J.H. ARUNDALE, PT, PhD • MARIO BIZZINI, PT, PhD • AIRELLE GIORDANO, DPT • TIMOTHY E. HEWETT, PhD
DAVID S. LOGERSTEDT, PT, PhD • BERT MANDELBAUM, MD • DAVID A. SCALZITTI, PT, PhD
HOLLY SILVERS-GRANELLI, PT, PhD • LYNN SNYDER-MACKLER, PT, ScD, FAPTA
SUMMARY OF RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A2
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3
J Orthop Sports Phys Ther 2018.48:A1-A42.
METHODS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A4
CLINICAL PRACTICE GUIDELINES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A7
AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS. . . . . . A22
REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A23
APPENDICES (ONLINE). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A26
REVIEWERS: Roy D. Altman, MD • Paul Beattie, PT, PhD • Marie Charpentier, DPT, ATC, LAT
John DeWitt, DPT, ATC • Amanda Ferland, DPT • Jennifer S. Howard, ATC, PhD
David Killoran, PhD • Leslie Torburn, DPT • James Zachazewski, DPT
For author, coordinator, contributor, and reviewer affiliations, see end of text. ©2018 Academy of Orthopaedic Physical Therapy, American Academy of Sports Physical
Therapy, and the Journal of Orthopaedic & Sports Physical Therapy. The Academy of Orthopaedic Physical Therapy, American Academy of Sports Physical Therapy, and
the Journal of Orthopaedic & Sports Physical Therapy consent to the reproduction and distribution of this guideline for educational purposes. Address correspondence
to Brenda Johnson, ICF-Based Clinical Practice Guidelines Coordinator, Academy of Orthopaedic Physical Therapy, APTA, Inc, 2920 East Avenue South, Suite 200, La
Crosse, WI 54601. E-mail: icf@orthopt.org
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
Summary of Recommendations*
REVIEW THE EVIDENCE IN THE SCIENTIFIC DESCRIBE THE EVIDENCE FOR COMPONENTS,
LITERATURE FOR EXERCISE-BASED KNEE DOSAGE, AND DELIVERY OF EXERCISE-BASED
INJURY PREVENTION PROGRAMS KNEE INJURY PREVENTION PROGRAMS
A Clinicians should recommend use of exercise-based knee A Exercise-based knee injury prevention programs used for
injury prevention programs in athletes for the prevention women should incorporate multiple components, proximal
of knee and anterior cruciate ligament (ACL) injuries. Programs control exercises, and a combination of strength and plyometric
for reducing all knee injuries include 11+ and FIFA 11, HarmoKnee, exercises.
and Knäkontroll; and those used by Emery and Meeuwisse,14
Goodall et al,20 Junge et al,34 LaBella et al,36 Malliou et al,41 Olsen A Exercise-based knee injury prevention programs should
et al,49 Pasanen et al,51 Petersen et al,52 and Wedderkopp et al.78 involve training multiple times per week, training sessions
Programs for reducing ACL injuries include HarmoKnee, Knäkon- that last longer than 20 minutes, and training volumes that are
troll, Prevent Injury and Enhance Performance (PEP), and Sports- longer than 30 minutes per week.
metrics; and those used by Caraffa et al,5 Heidt et al,27 LaBella et Clinicians, coaches, parents, and athletes should start
al,36 Myklebust et al,46 Olsen et al,49 and Petersen et al.52 A
exercise-based knee injury prevention programs in the
preseason and continue performing the program through the
IDENTIFY EXERCISE-BASED KNEE INJURY regular season.
PREVENTION PROGRAMS THAT ARE EFFECTIVE
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FOR SPECIFIC SUBGROUPS OF ATHLETES A Clinicians, coaches, parents, and athletes must ensure
high compliance with exercise-based knee injury
A Clinicians, coaches, parents, and athletes should imple-
prevention programs, particularly in female athletes.
ment exercise-based knee injury prevention programs
prior to athletic training sessions/practices or games in female Exercise-based knee injury prevention programs may not
B
athletes to reduce the risk of ACL injuries, especially in female need to incorporate balance exercises, and balance
athletes younger than 18 years of age. Programs that should be should not be the sole component of a program.
implemented include PEP, Sportsmetrics, Knäkontroll, Har-
moKnee, and those used by Olsen et al49 and Petersen et al.52
PROVIDE SUGGESTIONS FOR IMPLEMENTATION OF
Soccer players, especially women, should use exercise- EXERCISE-BASED KNEE INJURY PREVENTION PROGRAMS
J Orthop Sports Phys Ther 2018.48:A1-A42.
A
based knee injury prevention programs to reduce the risk of A Clinicians, coaches, parents, and athletes should imple-
severe knee and ACL injuries. Programs that could be beneficial for ment exercise-based knee injury prevention programs in
preventing severe knee injuries include PEP, Knäkontroll, and Har- all young athletes, not just those athletes identified through
moKnee. Programs that could be beneficial for specifically prevent- screening as being at high risk for ACL injury, to optimize the
ing ACL injuries include those used by Caraffa et al5 and numbers needed to treat while reducing cost.
Sportsmetrics.
A For the greatest reduction in future medical costs and
B Male and female team handball players, particularly those prevention of ACL injuries, osteoarthritis, and total knee
15 to 17 years of age, should implement exercise-based replacements, clinicians, coaches, parents, and athletes should
knee injury prevention programs. Programs that could be benefi- encourage implementation of exercise-based ACL injury preven-
cial for preventing knee injuries include those used by Olsen et tion programs in athletes 12 to 25 years of age and involved in
al49 and Achenbach et al.1 sports with a high risk of ACL injury.
a2 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
List of Abbreviations
11+: an injury prevention program developed originally in FIFA 11: also known as “the 11,” an injury prevention
association with the medical committee of FIFA (previously program developed originally in association with the
known as FIFA 11+) medical committee of FIFA and the predecessor to the 11+
ACL: anterior cruciate ligament ICD: International Classification of Diseases
AE: athlete-exposure ICF: International Classification of Functioning,
AMSTAR: A Measurement Tool to Assess Systematic Disability and Health
Reviews JOSPT: Journal of Orthopaedic & Sports Physical Therapy
APTA: American Physical Therapy Association KLIP: Knee Ligament Injury Prevention program
CI: confidence interval PEDro: Physiotherapy Evidence Database
CPG: clinical practice guideline PEP: Prevent Injury and Enhance Performance injury
EMG: electromyography prevention program
FIFA: Fédération Internationale de Football Association RCT: randomized controlled trial
(international soccer governing body) SIGN: Scottish Intercollegiate Guidelines Network
Introduction
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journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a3
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
Methods
The Academy of Orthopaedic Physical Therapy and the eates between evidence related to ACL injuries and all knee
American Academy of Sports Physical Therapy appointed injuries.
content experts with relevant physical therapy, medical, • Mechanism of injury included both contact (injuries as a
and surgical expertise as developers and authors of the result of collision with another person or object) and non-
CPG for exercise-based knee injury prevention. These contact (injuries that do not involve another individual or
experts were given the task of describing the interven- object).17 This CPG discusses contact and noncontact inju-
tions and evidence for exercise-based knee injury preven- ries together, unless specifically noted in the text.
tion. The authors declared relationships and developed a • Meta-analyses
conflict management plan, which included submitting a • Systematic reviews
Conflict of Interest form to the Academy of Orthopaedic • Randomized controlled trials (RCTs)
Physical Therapy, APTA, Inc. Funding was provided by the • Cost-effectiveness studies
Academy of Orthopaedic Physical Therapy and American • High-level cohort studies (critical appraisal score on the
Academy of Sports Physical Therapy, and by the APTA to Scottish Intercollegiate Guidelines Network [SIGN] check-
the CPG development team for travel and expenses for list of 5 or greater)
CPG development training. The CPG development team • Published in a peer-reviewed journal
maintained editorial independence. • Able to access full-text article
• Published and accessible in English
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Inclusion and exclusion criteria used to select relevant ar- • Non–exercise-based interventions (eg, prophylactic
ticles were as follows. bracing)
• Case series
INCLUSION CRITERIA • Case-control studies
• Exercise-based knee injury prevention • Case studies
- Studies needed to expressly state that knee injuries of any
kind were the specific target of the program and outcome This guideline focuses on exercise-based knee injury pre-
measure of the study. vention programs, and excludes broader programs aimed at
- Exercise-based prevention was defined as an intervention preventing lower extremity injuries. Lower extremity injury
requiring the participant to be active and move his or her prevention programs target a wide range of pathologies,
body. This could include physical activity; strengthen- thus selecting different exercises or focusing athlete feed-
ing; stretching; neuromuscular, proprioceptive, agility, back on joints other than the knee. Further, mechanisms of
or plyometric exercises; and other training modalities, prevention may also differ. Programs targeting risk factors
but excluded passive interventions such as bracing or for knee injuries (eg, programs focused on modifying knee
programs that only involved education. biomechanics during jump landing) were also excluded from
- Knee injuries were defined as any knee joint pathology this CPG. There are a number of modifiable and nonmodifi-
including damage to the joint (patellofemoral and/or tib- able risk factors for knee injuries. However, the magnitude
iofemoral), ligaments, meniscus, or patellar tendon. of each risk factor for an athlete can be dependent on many
• Articles that focused on preventing knee injuries as a other variables. For example, hormonal changes as a result
whole were included, but so too were articles focused on of menstruation may affect women but not men.21 Similarly,
only one type of knee injury (eg, anterior cruciate ligament asymmetries in jump landing have been associated with knee
[ACL] injuries or patellofemoral pain). This CPG delin- injuries in women31 but not, to date, in men. As an inter-
a4 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
Methods (continued)
national group of experts in prevention, familiar with the (see APPENDIX E for quality-assessment scores, available at
prevention literature as a whole as well as that specific to www.orthopt.org). Recommendations were written based
knee injuries, the authors felt that these were appropriate on the included articles and were agreed on by all authors.
restrictions. APPENDICES A through J are available on the CPG web page
at www.orthopt.org.
Components of training programs were defined as different
exercise approaches involved in the prevention programs. This guideline was issued in 2018 based on the published lit-
For example, a program that only involved balance exercises erature up to October 2017. This guideline will be considered
was considered to only have 1 component, whereas a program for review in 2022, or sooner if significant new evidence be-
that involved strengthening and plyometric exercises was comes available. Any updates to the guideline in the interim
considered to have multiple components. Common compo- period will be noted on the Academy of Orthopaedic Physical
nents include flexibility, strengthening, plyometrics, balance, Therapy website (www.orthopt.org).
and agility.
LEVELS OF EVIDENCE
One author (D.S.) screened articles for full-text availabil- Articles were graded according to criteria adapted from the
ity and for publication in English and in peer-reviewed Centre for Evidence-based Medicine, Oxford, United King-
journals. Two authors (A.A. and A.G. or D.L.) then inde- dom for diagnostic, prospective, and therapeutic studies.56
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pendently screened articles for inclusion based on title In 4 teams of 2, authors came to consensus to assign a level
and abstract. The authors then discussed their findings. of evidence based on the quality assessment of each article
Any article that clearly did not meet inclusion criteria (see APPENDICES F and G for the evidence table and details on
based on title and abstract was excluded at this point, and procedures used for assigning levels of evidence, available
the full text of any article that the authors were unsure at www.orthopt.org). An abbreviated version of the grading
of or that seemed to clearly meet inclusion criteria was system is provided below.
then reviewed. Full-text reviews were performed indepen-
dently by the same authors. The authors met to review Evidence obtained from systematic reviews, high-quality diagnos-
I
their findings, and all disagreements on inclusion/exclu- tic studies, prospective studies, or randomized controlled trials
sion were resolved by discussion. Consensus was reached Evidence obtained from systematic reviews, lesser-quality diag-
J Orthop Sports Phys Ther 2018.48:A1-A42.
on all articles (see APPENDIX C for the flow chart of articles nostic studies, prospective studies, or randomized controlled
II
and APPENDIX D for the citations of articles included in this trials (eg, weaker diagnostic criteria and reference standards,
guideline, available at www.orthopt.org). improper randomization, no blinding, less than 80% follow-up)
III Case-control studies or retrospective studies
All authors were involved in the quality-assessment and da- IV Case series
ta-extraction process. Two authors independently assessed V Expert opinion
the quality of each article. The A Measurement Tool to As-
sess Systematic Reviews (AMSTAR) tool was used to assess GRADES OF EVIDENCE
the quality of meta-analyses and systematic reviews.58 The In teams of 2, the authors developed recommendations
Physiotherapy Evidence Database (PEDro) scale was used based on the strength of evidence, including how directly
to assess the quality of RCTs,75 the SIGN checklist was used the studies addressed exercise-based knee injury prevention
to assess the quality of cohort studies,59 and the Drummond programs. The strength of the evidence supporting each
checklist was used to assess the quality of cost-effectiveness recommendation was graded according to the previously
analyses.12 Authors established reliability in the use of each established methods and is provided on the next page. In
quality-appraisal tool by independently assessing articles developing their recommendations, the authors considered
not included in the CPG, discussing their scoring, and com- the strengths and limitations of the body of evidence and the
ing to consensus on areas of disagreement. Discrepancies in health benefits and risks of interventions.
quality ratings were resolved through discussion between
the 2 authors. Studies that were authored by a reviewer DESCRIPTION OF GUIDELINE REVIEW PROCESS AND VALIDATION
were assigned to an alternate reviewer. Studies with a quali- Identified reviewers who are experts in knee injury preven-
ty score less than 5 on any scale were considered low quality tion reviewed the CPG draft for integrity, accuracy, and to
and were not used in the development of these guidelines39 ensure that it fully represented the current evidence for the
journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a5
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
Methods (continued)
GRADES OF RECOMMENDATION STRENGTH OF EVIDENCE holders, and experts in physical therapy practice guideline
Strong evidence A preponderance of level I and/or level II methodology.
A studies support the recommendation. This
must include at least 1 level I study DISSEMINATION AND IMPLEMENTATION TOOLS
Moderate A single high-quality randomized controlled In addition to publishing this guideline in the Journal of
B evidence trial or a preponderance of level II studies Orthopaedic & Sports Physical Therapy (JOSPT), it will be
support the recommendation
highlighted and posted on the CPG web page of the JOSPT
Weak evidence A single level II study or a preponderance of
and the Academy of Orthopaedic Physical Therapy (APTA)
level III and IV studies, including statements
C websites. These web pages have unrestricted public access.
of consensus by content experts, support the
recommendation Implementation tools and associated implementation strat-
Conflicting Higher-quality studies conducted on egies that will be made available for athletes, coaches, pa-
evidence this topic disagree with respect to their tients, physicians, surgeons, clinicians, educators, payers,
D
conclusions. The recommendation is policy makers, and researchers are listed in TABLE 1.
based on these conflicting studies
Theoretical/ A preponderance of evidence from animal CLASSIFICATION
foundational or cadaver studies, from conceptual models/ The primary International Classification of Diseases-10th Re-
E
evidence principles, or from basic science/bench vision (ICD-10) codes and conditions associated with exercise-
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experts, academic educators, clinical educators, physician ing basic body positions, d450 Walking, d4552 Running,
specialists, and researchers, also reviewed the guideline. d4553 Jumping, d4559 Moving around, specified as di-
All comments, suggestions, and feedback from the expert rection changes while walking or running, d9200 Play,
reviewers, public, and consumer/patient representatives d9201 Sports, and d9202 Arts and culture.
were provided to the authors and editors for consideration
and revisions. Guideline development methods, policies, ORGANIZATION OF THE GUIDELINES
and implementation processes are reviewed at least yearly Topics are arranged in relation to the CPG objectives. For each
by the Academy of Orthopaedic Physical Therapy (APTA)’s objective, the summaries of the evidence, levels of evidence,
ICF-Based Clinical Practice Guideline Advisory Panel, in- recommendation(s), and grade(s) of recommendation(s) are
cluding consumer/patient representatives, external stake- provided.
a6 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
tions.9,18,57 One meta-analysis examined the efficacy knee injury prevention programs, including reduction in risk
in reducing all knee injuries as well as reducing ACL injuries for all knee injuries and for ACL injuries specifically, with
specifically,9 and 2 focused only on ACL injuries.18,57 All of the little risk of adverse events and minimal cost.
studies included in these meta-analyses involved athletes
(sporting or tactical/military), with participants being men Recommendation
and women of different ages and races, as well as with differ- Clinicians should recommend use of exercise-based
ent sports and skill levels. A knee injury prevention programs in athletes for the
prevention of knee and ACL injuries. Programs for
The exercise-based prevention programs included in these reducing all knee injuries include 11+ and FIFA 11, Har-
analyses employed a number of different intervention strat- moKnee, and Knäkontroll; and those used by Emery and
J Orthop Sports Phys Ther 2018.48:A1-A42.
egies, from neuromuscular and proprioceptive training to Meeuwisse,14 Goodall et al,20 Junge et al,34 LaBella et al,36
strengthening, stretching, and plyometric exercises. Many of Malliou et al,41 Olsen et al,49 Pasanen et al,51 Petersen et al,52
these programs employed more than one of these strategies, and Wedderkopp et al.78 Programs for reducing ACL injuries
and gave participants feedback on their form during exer- include HarmoKnee, Knäkontroll, Prevent Injury and
cises, particularly jump landings.9,18,57 Enhance Performance (PEP), and Sportsmetrics; and those
used by Caraffa et al,5 Heidt et al,27 LaBella et al,36 Myklebust
The pooled incidence rate ratio, based on 19 studies (n = et al,46 Olsen et al,49 and Petersen et al.52
19 143), indicated that exercise-based prevention programs
are effective in reducing the incidence of knee injuries (inci-
dence rate ratio = 0.73; 95% confidence interval [CI]: 0.61, OBJECTIVE
0.87).9 Programs in the meta-analysis showing efficacy in Identify exercise-based knee injury prevention programs that
reducing knee injuries include FIFA (Fédération Internatio- are effective for specific subgroups of athletes. Evidence in-
nale de Football Association) 11+25,61 and FIFA 11 ("The 11"),73 cludes systematic reviews, meta-analyses, and cohort stud-
HarmoKnee,35 and Knäkontroll77; and those used by Emery ies that specifically delineate populations (APPENDICES I and J,
and Meeuwisse,14 Goodall et al,20 Junge et al,34 LaBella et al,36 available at www.orthopt.org).
Malliou et al,41 Olsen et al,49 Pasanen et al,51 Petersen et al,52
and Wedderkopp et al.78 Evidence
Men
Pooled rate and risk ratios from the 3 meta-analyses9,18,57 ex- One systematic review examined the effects of exer-
amining the impact of exercise-based knee injury prevention
programs on incidence of primary ACL injuries indicate that
II cise-based prevention programs on ACL injuries in
only men.2 The review by Alentorn-Geli et al2 found
these programs are effective.18,57 Gagnier et al18 examined 14 that studies of exercise-based knee prevention programs in
journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a7
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
men were primarily performed on soccer teams. The review greater reduction in ACL injuries (odds ratio = 0.27-0.28)
identified 1 program successful in reducing ACL injury rates. compared to women over 18 years of age (odds ratio = 0.78-
The Caraffa et al5 program reported ACL injury rates in the 0.84).45,80 Analyzing age based on tertiles, Myer et al45 found
intervention group of 0.15 ACL injuries per team per year and a statistically significant reduction in ACL injuries for the
in the control group of 1.15 ACL injuries per team per year. The youngest group, but not for the older 2 groups: ages 14 to 18
review also identified a study by Grooms et al25 that examined years (odds ratio = 0.28; 95% CI: 0.18, 0.42), ages 18 to 20
the 11+ program. Using a 1-season historical control, Grooms years (odds ratio = 0.48; 95% CI: 0.21, 1.07), and ages older
et al25 did not observe an ACL injury in either the control or than 20 years (odds ratio = 1.01; 95% CI: 0.62, 1.64).45 An
intervention season. additional study analyzed age in quartiles. Sugimoto et al68
found that female athletes 14 to 18 years of age had greater
Women reduction in ACL injury incidence (odds ratio = 0.29; 95%
Three meta-analyses indicate that, in women, exer- CI: 0.19, 0.44; P = .01) compared to those younger than 14
I cise-based injury prevention programs are effective
in reducing the risk of all ACL injuries, with pooled
years of age (odds ratio = 0.29; 95% CI: 0.01, 7.09; P = .45),
18 to 20 years of age (odds ratio = 0.48; 95% CI: 0.21, 1.07;
odds ratios ranging from 0.40 to 0.64.45,72,80 More specifically, P = .07), and older than 20 years of age (odds ratio = 1.01;
when reporting only noncontact ACL injuries, the pooled 95% CI: 0.62, 1.64; P = .97).
odds ratio was 0.38.72,80
Soccer
Programs identified by meta-analyses45,72,80 as being effec- A meta-analysis of RCTs found a protective effect
tive in reducing the risk for ACL injuries in women were the
PEP, Sportsmetrics, Knäkontroll, and HarmoKnee, as well
I of exercise-based knee injury prevention programs
in soccer players (men and women) for knee inju-
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as the programs used in the studies by Myklebust et al46 and ries (relative risk = 0.74; 95% CI: 0.55, 0.98). The study
Petersen et al.52 Common themes of these successful pro- found a reduction in ACL injuries, though this decrease in
grams were use of multiple types of exercises, participation incidence was not statistically significant (relative risk =
during the preseason or preseason and in-season, perfor- 0.66; 95% CI: 0.33, 1.32).22 Three prevention programs,
mance prior to training sessions/practices or games, and an however, were successful in significantly decreasing the inci-
emphasis on what is thought to be optimal lower extremity dence of ACL injuries in soccer players when compared to a
alignment.19,27,29,35,36,42,46,49,52,63,77 control group (PEP,42 Knäkontroll,77 and the program used
by Caraffa et al5).
Two programs were identified as being ineffective at prevent-
ing ACL injuries.72,80 The Knee Ligament Injury Prevention Three individual studies included in this CPG (using the PEP,
J Orthop Sports Phys Ther 2018.48:A1-A42.
(KLIP) exercise-based knee injury prevention program, used Knäkontroll, and HarmoKnee programs) examined the in-
by Pfeiffer et al54 with high school–aged adolescent girls and cidence of knee injuries.29,35,77 While all 3 studies showed a
women, was used after practices and games. Despite an odds decrease in the incidence of knee injuries,29,35,77 the reduc-
ratio of 2.05, suggesting a greater risk of incurring a noncon- tion was only statistically significant with the Knäkontroll
tact ACL injury for the athletes in their intervention group, program.77 All 7 individual studies included in this CPG
the wide 95% CI (0.21, 21.7) indicates a lack of statistical that examined ACL injury incidence in soccer players (PEP,
significance. Söderman et al60 found that a greater percentage Knäkontroll, KLIP, the program by Caraffa et al,5 Sportsmet-
of athletes in their intervention group incurred noncontact rics) found a decrease in ACL injuries.19,29,35,42,54,77
ACL injuries (intervention, 6.5%; control, 1.3%; no P value
reported) or other knee injuries, including those to the com- In female soccer players (n = 4564) between the
bined ACL and medial collateral ligament, medial collateral
ligament, lateral collateral ligament, posterior cruciate liga-
II ages of 12 and 17 years, the Knäkontroll program
reduced ACL injuries in the intervention group by
ment, and contusions (intervention, 12.9%; control, 7.7%; no 64% (rate ratio = 0.36; 95% CI: 0.15, 0.85) and severe knee
P value reported), than those in their control group. Unlike injuries by 30% (rate ratio = 0.70; 95% CI: 0.42, 1.18).77
the effective programs that involved multiple exercise mo-
dalities, the Söderman et al60 program only involved balance- Two studies examined the efficacy of the PEP program in re-
board training. ducing ACL injuries in female soccer players. Mandelbaum et
al42 examined adolescent girls and women aged 14 to 18 years
Adolescent female athletes seem to gain the most and found an 89% decrease (rate ratio = 0.11; 95% CI: 0.03,
I benefit from exercise-based knee injury prevention
programs.45,68,80 Two meta-analyses examined the
0.48) in ACL injuries compared to age- and skill-matched
control athletes in the first season of the PEP program, and
effect of age, finding that girls under 18 years of age have a a 74% decrease (rate ratio = 0.26; 95% CI: 0.09, 0.85) in the
a8 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
second season of use. Gilchrist et al19 examined college-aged basketball intervention group. Although this was not a sta-
women and found lower, but nonsignificant, differences in tistically significant difference in incidence (intervention,
rates of ACL injuries in their intervention (0.20/1000 athlete- 0.42 injuries/1000 AEs; control, 0.48 injuries/1000 AEs; P
exposures [AEs]) compared to their control (0.34/1000 AEs) = .17), it was a positive trend following their 6-week, pre-
group (P = .20).19 The results were similar (lower but nonsig- season, 60- to 90-minute plyometric-based program. Female
nificant rates) when they examined noncontact ACL injuries basketball players who performed their intervention had sig-
specifically (intervention, 0.06/1000 AEs; control, 0.19/1000 nificantly fewer noncontact knee injuries compared to con-
AEs). There was a higher rate, though not significant, of overall trol female basketball players (P = .02). In contrast, Pfeiffer
knee injuries in their intervention group (1.14/1000 AEs) com- et al54 observed a 4-fold greater risk of noncontact ACL injury
pared to their control group (1.10/1000 AEs, P = .86). in their intervention group compared to the control group
(intervention, 0.48 ACL injuries per 1000 AEs; control,
Studies that have examined female soccer and team 0.11/1000 AEs) following their 15- to 20-minute program
II handball players have shown effectiveness in reduc-
ing ACL injuries (soccer: odds ratio = 0.32; 95%
that was performed after training sessions.
CI: 0.19, 0.56; team handball: odds ratio = 0.54; 95% CI: Volleyball
0.30, 0.97).80 However, making direct comparisons of effec- No conclusions can be drawn with regard to exer-
tiveness between sports needs to be done with caution, be-
cause the exercise-based knee injury prevention programs
II cise-based knee injury prevention programs in fe-
male volleyball players. Two studies included
used in each cohort were not identical. volleyball players, but neither study observed the outcome of
interest (serious knee injury or ACL injury) in either the in-
Team Handball tervention or the control group.29,54
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journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a9
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
Programs that could be beneficial for specifically preventing ing exercises failed to reduce ACL injuries (odds ratio = 1.02;
ACL injuries include those used by Caraffa et al 5 and 95% CI: 0.63, 1.64).67
Sportsmetrics.
Programs without balance training components
Male and female team handball players, particu- II (Sugimoto et al67: odds ratio = 0.34; CI: 0.20,
B larly those 15 to 17 years of age, should implement
exercise-based knee injury prevention programs.
0.56; Yoo et al80: odds ratio = 0.27; CI: 0.14, 0.49)
are effective in preventing ACL injuries in women. There
Programs that could be beneficial for preventing knee inju- are differing results regarding whether programs with bal-
ries include those used by Olsen et al49 and Achenbach et al.1 ance training components are effective (Sugimoto et al 67:
odds ratio = 0.59; CI: 0.42, 0.83; Yoo et al80: odds ratio =
0.63; CI: 0.37, 1.09). Taylor et al72 found that as the dura-
OBJECTIVE tion of time within a program spent performing balance
Describe the evidence for components, dosage, and delivery exercises increased, the protective effect of the program
of exercise-based knee injury prevention programs. decreased.
sulted in ACL injury reductions (odds ratio = 0.32; 95% CI: Sadoghi et al57 performed a meta-regression to de-
0.22, 0.46). In contrast, programs with only a single exercise
component did not result in a significant reduction of injuries
II termine the factors that influence the effect of an
exercise-based knee injury prevention program in
(odds ratio = 1.15; 95% CI: 0.70, 1.89).67 women. They found that use of balance boards (P = .71), use
of video assistance (P = .91), duration of follow-up (P = .44),
Exercise-based knee injury prevention programs in and year of study publication (P = .36) did not influence a
I women that include proximal control exercises,
such as trunk/core strengthening and stability ex-
program’s ACL injury risk reduction.
ercises, led to significantly lower ACL injury rates (odds ratio Dosage and Delivery
= 0.33; 95% CI: 0.23, 0.47). In contrast, programs that did Gagnier et al18 performed a meta-analysis including
J Orthop Sports Phys Ther 2018.48:A1-A42.
a10 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
ratio = 0.66; 95% CI: 0.43, 0.99). Programs that lasted 20 Compliance
minutes or less per session had an odds ratio of 0.61 (95% Sugimoto et al69 performed a meta-analysis of stud-
CI: 0.41, 0.90) in reducing ACL injuries, whereas pro-
grams that lasted longer than 20 minutes per session had
I ies involving female soccer, basketball, volleyball,
and team handball athletes, concluding that higher
an odds ratio of 0.35 (95% CI: 0.23, 0.53). Exercise-based rates of compliance with exercise-based injury prevention
injury prevention programs implemented multiple times programs were associated with lower rates of ACL injury in-
per week had an odds ratio of 0.35 (95% CI: 0.23, 0.53) in cidence among adolescent female athletes. The authors
reducing ACL injuries compared to programs that only found that when compliance was dichotomized (greater than
used training once a week, which had an odds ratio of 0.62 versus less than 42.5% overall compliance rate*), the inci-
(95% CI: 0.41, 0.94). dence rate in the high-compliance group was 73% lower (in-
cidence rate ratio = 0.27; 95% CI: 0.07, 0.80). When divided
Donnell-Fink et al9 examined men and women, into tertiles (greater than 66.6%, 33.3%-66.6%, less than
I comparing preseason-only and preseason-plus-in-
season programs to in-season-only programs, and
33.3% overall compliance), the high-compliance group had
82% lower ACL injury incidence (incidence rate ratio = 0.18;
found lower risk for knee injuries when preseason was in- 95% CI: 0.02, 0.77) than the medium- and low-compliance
cluded (preseason/preseason-plus-in-season incidence rate groups. The authors reported that a potential inverse dose-
ratio = 0.24; in-season-only rate ratio = 0.75; no CIs pre- response relationship exists between compliance with an
sented; P<.01). They did not find a significant result with this exercise-based injury prevention program and the incidence
same comparison for ACL injuries specifically (preseason/ of ACL injury in adolescent female athletes. *Overall compli-
preseason-plus-in-season incidence rate ratio = 0.32; in- ance rate was defined as the attendance rate multiplied by the
season-only rate ratio = 0.57; P = .33).9 compliance rate, with attendance rate defined as the number
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Sugimoto et al68 performed a meta-regression ex- exercise-based prevention programs.35,77 Kiani et al,35 using
I amining the “synergistic effects” of components of
exercise-based knee injury prevention programs
the HarmoKnee program, found a 77% lower incidence of
knee injuries (rate ratio = 0.23; 95% CI: 0.04, 0.83) and a
that they deemed key to optimizing ACL injury prevention. 90% lower incidence of noncontact knee injuries (rate ratio
They grouped age in tertiles (14-18 years, 18-20 years, 20 = 0.10; 95% CI: 0.00, 0.70). These reductions in knee injury
years or older), dosage was dichotomized (20 minutes or less risk decreased further when they were adjusted for compli-
per session, greater than 20 minutes per session), frequency ance (removal of 3 teams that performed the intervention
was dichotomized (once per week, multiple times per week), with less than 75% compliance, leaving 45 teams in the inter-
number of exercises was dichotomized (programs made up vention group). Athletes who were compliant with the Har-
of only 1 exercise component, programs made up of multiple moKnee program had an 83% reduction in knee injury
components), and verbal feedback to athletes on their form incidence (rate ratio = 0.17; 95% CI: 0.04, 0.64) and a 94%
was dichotomized (verbal feedback given, no verbal feed- decrease in noncontact knee injuries (rate ratio = 0.06; 95%
back). Points were assigned to groups based on previously CI: 0.01, 0.46).
reported odds ratios, with higher points given to groupings
that demonstrated lower odds ratios (greater ACL injury re- Waldén et al,77 using the Knäkontroll program in a
duction). Groups with the highest points were those aged 14
to 18 years, programs greater than 20 minutes in duration,
II cluster RCT, found an overall 64% decrease in ACL
injury incidence (rate ratio = 0.36; 95% CI: 0.15,
programs performed multiple times per week, and programs 0.85) in their intervention group compared to controls, but
with multiple exercise components. The results indicated an when they examined only their compliant players (defined as
odds ratio of 0.83 (β1 = –0.29; 95% CI: –0.33, –0.03; P = players having performed the intervention once per week on
.03), or 17% lower odds of sustaining an ACL injury if one of average), they found an 83% reduction in ACL injury rate
these highest-point groups was present. (rate ratio = 0.17; 95% CI: 0.05, 0.57). They also found that
journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a11
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
Evidence Synthesis
I Sugimoto et al,70 examining 12 studies (including all
5 studies reviewed by Grindstaff et al24), to determine
There is evidence of important benefits of exercise-based the effectiveness of exercise-based injury prevention programs
knee injury prevention programs, including reduction of risk designed to reduce ACL injury risk and noncontact ACL injury
Downloaded from www.jospt.org by 140.213.58.240 on 12/16/18. For personal use only.
for knee and/or ACL injuries, with little risk of adverse events risk in female athletes. Sugimoto et al70 reported that to
and minimal cost. prevent 1 ACL injury during a sports season, 120 athletes (95%
CI for number needed to benefit: 74, 316) would need to par-
Recommendations ticipate in an exercise-based knee injury prevention program.
Exercise-based knee injury prevention programs The relative risk reduction for ACL injury was 43.8% (95% CI:
A used for women should incorporate multiple
components, proximal control exercises, and a
28.9%, 55.5%) in athletes involved in the prevention pro-
grams. Over the course of 1 season, to prevent 1 noncontact
combination of strength and plyometric exercises. ACL injury, 108 athletes (95% CI for number needed to ben-
efit: 86, 150) would have to participate in an exercise-based
Exercise-based knee injury prevention programs knee injury prevention program, with a relative risk reduction
J Orthop Sports Phys Ther 2018.48:A1-A42.
a12 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
that the strategy of training 12- to 25-year-olds in high-risk ACL injury; 95% CI: 73, 303), but a slightly higher relative
sports would prevent the most ACL injuries, with the lowest risk reduction of 48.2% (95% CI: 22%, 65%), compared to
number needed to treat, as well as prevent the highest num- coach-led programs, which had a number needed to benefit
ber of future knee injuries and total knee replacements (pre- of 131 (95% CI: 98, 196) and a relative risk reduction of
vented 3764 ACL injuries [number needed to treat, 27], 842 58.4% (95% CI: 40%, 71%).
knee osteoarthritis cases, and 584 total knee replacements
per 100 000 treated). Training 18- to 25-year-olds in high- Evidence Synthesis
risk sports prevented the next largest number of ACL injuries There is no increase in risk of adverse events when all ath-
and resulted in the smallest number needed to treat (pre- letes perform prevention programs compared to only athletes
vented 2303 ACL injuries [number needed to treat, 43], 511 screened as high risk, and there is no harm in performing
osteoarthritis cases, and 353 total knee replacements per prevention programs. Although cost may minimally increase
100 000 treated), followed by 12- to 17-year-olds in high-risk (depending on the program) as more athletes participate, the
sports (prevented 2021 ACL injuries [number needed to small increase in program costs is likely outweighed by long-
treat, 49], 457 osteoarthritis cases, and 317 total knee re- term health care costs and by the reduction in ACL injuries.
placements per 100 000 treated), and 12- to 17-year-olds in
all sports (prevented 526 ACL injuries [number needed to Recommendation
treat, 190], 119 osteoarthritis cases, and 83 total knee re- Clinicians, coaches, parents, and athletes should
placements per 100 000 treated). A implement exercise-based knee injury prevention
programs in all young athletes, not just those ath-
Swart et al71 performed a cost-effectiveness analysis letes identified through screening as being at high risk for
II on prevention and screening programs for ACL in- ACL injury, to optimize the numbers needed to treat while
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Pfile and Curioz55 performed a number-needed-to- Clinicians, coaches, parents, and athletes should
II treat analysis examining exercise-based ACL injury
prevention programs led by coaches versus pro-
B support implementation of exercise-based knee in-
jury prevention programs led by either coaches or
grams led by what they termed a mixed leadership group (ie, a group of coaches and medical professionals.
coaches, physical therapists, and/or athletic trainers). Pro-
grams led by a mixed leadership group had a lower number The recommendations made in this guideline are summa-
needed to benefit (120 athletes needed to treat to prevent 1 rized in FIGURES 1 and 2.
journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a13
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
Programs for reducing all knee injuries include 11+ and FIFA 11, HarmoKnee, and Knäkontroll; and those used by Emery and Meeuwisse,14 Goodall
et al,20 Junge et al,34 LaBella et al,36 Malliou et al,41 Olsen et al,49 Pasanen et al,51 Petersen et al,52 and Wedderkopp et al78
Programs for reducing ACL injuries include HarmoKnee, Knäkontroll, Prevent Injury and Enhance Performance (PEP), and Sportsmetrics; and those
used by Caraffa et al,5 Heidt et al,27 LaBella et al,36 Myklebust et al,46 Olsen et al,49 and Petersen et al52
Female athletes (especially those under Soccer players Team handball players
18 years of age)
Specific populations
PEP, Sportsmetrics, Knäkontroll, Programs that could be beneficial for Olsen et al,49 Achenbach et al1
HarmoKnee, Olsen et al,49 preventing knee injuries: PEP,
Petersen et al52 Knäkontroll, and HarmoKnee
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Implementation
All young athletes, not just those screened as high risk, particularly athletes aged 12 to 25 years participating in high-risk sports (defined as rugby,
Australian rules football, netball, soccer, basketball, and skiing)
FIGURE 1. Treatment algorithm based on clinical practice guideline findings. The exercise-based knee injury prevention programs heading summarizes the programs observed
to be effective when studied across populations. Below the exercise-based knee injury prevention programs heading are the specific populations. These 2 groups (exercise-
based knee injury prevention and specific populations) are not mutually exclusive; all programs found in the specific populations area are also found in the exercise-based knee
injury prevention area. However, the program listed for specific populations may be more effective or may have been studied in detail in that particular group. The dosage and
delivery and implementation sections provide a summary of recommendations on how programs should be set up and executed.
a14 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
Tool Strategy
“Perspectives for Patients” and videos for clinicians, coaches, and athletes Patient-oriented guideline summary available on www.jospt.org and
www.orthopt.org (FIGURES 1 and 2, TABLE 2)
Mobile applications of guideline-based exercises for patients/clients, athletes, Marketing and distribution of app using www.orthopt.org
coaches, and health care practitioners
Clinician’s quick-reference guide Summary of guideline recommendations available on www.orthopt.org
Read-for-credit continuing education content Continuing education content available for physical therapists and athletic
trainers from JOSPT
Webinar-based educational offerings for health care practitioners Guideline-based instruction available for practitioners on www.orthopt.org
Mobile and web-based applications for health care practitioner training Marketing and distribution of app using www.orthopt.org
Non-English versions of the guidelines and guideline Development and distribution of translated guidelines and tools to JOSPT’s
implementation tools international partners and global audience via www.jospt.org
Area/Study or Program Equipment Needed Time for Each Activity Activities/Muscles Included in Program
Flexibility
HarmoKnee None Muscle activation: approximately 2 minutes • Standing calf stretch
of total time, holding position and • Standing quadriceps stretch
contracting the muscle for approximately • Half-kneeling hamstring stretch
4 seconds, focusing on “finding” your • Half-kneeling hip flexor stretch
muscles. Stretching is only recommend- • Butterfly adductor stretch
ed in cases of limited range of motion • Modified figure-of-four stretch
PEP None 50 yd each, 30 × 2 repetitions each • Calf stretch
• Quadriceps stretch
• Figure-of-four hamstring stretch
• Inner thigh stretch
• Hip flexor stretch
J Orthop Sports Phys Ther 2018.48:A1-A42.
journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a15
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
Area/Study or Program Equipment Needed Time for Each Activity Activities/Muscles Included in Program
PEP None 50 yd each, 2 repetitions each • Jog from line to line of soccer field (cone to cone)
• Shuttle run (side to side)
• Backward running
• Shuttle run with forward/backward running (40 yd)
• Diagonal runs (40 yd)
• Bounding run (45-50 yd)
Sportsmetrics None 3 sets of 30 seconds each, or 2 laps • Skipping
• Side shuffle
• Cool-down walk (2 minutes)
Balance
Achenbach et al1 Ball optional Not specified • Standing on 1 leg with eyes closed, try to destabilize the partner by pressing against
their body
Caraffa et al5 Rectangular wobble 2.5 minutes, 4 times a day for each exercise • Phase 1: single-leg stance, no board
board, round • Phase 2: single-leg stance on rectangular board (on 45°)
balance board, • Phase 3: single-leg stance on round board
combined round/ • Phase 4: single-leg stance on a combined round and rectangular board
rectangular • Phase 5: single-leg stance on a BAPS board
board, BAPS
board
Myklebust et al46 Balance mat, wobble Not specified • Single-leg stance on mat with throw
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a16 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
Area/Study or Program Equipment Needed Time for Each Activity Activities/Muscles Included in Program
PEP None Varies based on exercise • Walking lunges, 20 yd × 2 sets
• Russian hamstring, 3 sets × 10 repetitions or 30 seconds
• Single toe raises, 30 repetitions each side
Sportsmetrics Weight equipment/ 1 set of 12 repetitions for upper body, 1 set of • Back hyperextension
machines 15 repetitions for trunk and lower body • Leg press
• Calf raise
• Pullover
• Bench press
• Latissimus dorsi pull-down
• Forearm curl
Core stability
Achenbach et al1 None Not specified • Plank
• Side plank
HarmoKnee None 1 minute each • Sit-ups
• Plank on elbows
• Bridging
Knäkontroll None 15-30 seconds • Level 1: prone plank on knees
• Level 2: prone plank on toes
• Level 3: prone plank on toes with lateral step
• Level 4: side plank
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HarmoKnee Ball optional 30 seconds each • Forward and backward double-leg jumps
• Lateral single-leg jumps
• Forward and backward single-leg jumps
• Double-leg jump with or without ball
KLIP None 4 phases, each lasting 2 wk. Time/repeti- • Straight jumps
tions for each exercise not specified • Tuck jumps
• Standing broad jump
• Bound in place
• 180° jump
• Single-leg lateral leaps
• 45° lateral leaps
• Combination jumps
• Single-leg forward hops
• Single-leg 45° lateral hops
• Single-leg forward hops × 3
Knäkontroll None 3 sets, 5-15 repetitions • Level 1: single-leg forward/backward hops
• Level 2: double-leg lateral jumps, landing on single leg
• Level 3: take a few quick steps on same spot and make short jump straight forward,
landing on 1 foot
• Level 4: take a few quick steps on same spot and make short jump, but change direc-
tion and jump to 1 side (90° turn); alternate sides
• Level 5 (partner exercise): partner stands in front of you approximately 5 m away;
make 2-legged jump while heading soccer ball and land on 2 legs
Myklebust et al46 None Not specified • Run and plant
• Double-leg jump forward/backward; partner pushes player (perturbation)
• Jump shot (handball) from 30- to 40-cm box with soft landing
• Step off 30- to 40-cm box with single-leg landing
Table continues on page A18.
journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a17
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
Area/Study or Program Equipment Needed Time for Each Activity Activities/Muscles Included in Program
Olsen et al49 None 4 minutes and 5 × 30 seconds each • Jump-shot landings
• Forward jumps
PEP Cones (5-15 cm tall) 20 repetitions or 30 seconds each • Lateral hops over cone
• Forward/backward hops over cone
• Single-leg hops over cone
• Vertical jumps with headers
• Scissors jump
Sportsmetrics None Varies based on exercise • Wall jumps (20 seconds, progressing to 30 seconds)
• Tuck jumps (20 seconds, progressing to 30 seconds)
• Broad jumps, stick (hold) landing (5-10 repetitions)
• Squat jumps (10 seconds, progressing to 25 seconds)
• Double-legged cone jumps (30 seconds/30 seconds side to side and back to front)
• 180° jumps (20-25 seconds)
• Bounding in place (20-25 seconds)
• Jump, jump, jump, vertical jump (5-8 repetitions)
• Bounding for distance (1-2 runs)
• Scissors jump (30 seconds)
• Hop, hop, stick landing (5 repetitions per leg)
• Step, jump up, down, vertical (5-10 repetitions)
• Mattress jumps (30 seconds/30 seconds side to side and back to front)
• Single-legged jumps for distance (5 repetitions per leg)
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a18 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
Olsen et al49 Cluster Intervention, n = 958 Through one 8-month team Significant reduction in all injuries (relative risk = 0.49; None
RCT Control, n = 879 handball season (15-20 95% CI: 0.39, 0.63; P<.01)
Female team handball players minutes, 15 consecutive train- Acute knee injuries: relative risk = 0.45; 95% CI: 0.25,
aged 16-17 y ing sessions at the start of the 0.81; P<.01
season, followed by once per Number of athletes needed to treat to prevent 1 acute
week for the remainder of the knee injury was 43
season) Significant reduction in knee ligament injuries (relative
risk = 0.20; 95% CI: 0.06, 0.70; P = .01)
Nonsignificant reduction in meniscal injuries (relative
risk = 0.27; 95% CI: 0.06, 1.28; P = .10)
PEP
Gilchrist et al19 Cluster Control, n = 852 12 weeks through collegiate soc- Overall, no significant difference in injury rates for all One player tripped
RCT Intervention, n = 583 cer season (15-20 minutes, 3 knee injuries (P = .86) or ACL injuries (P = .20) during the lateral
NCAA Division I female soccer times per week) The intervention group had a lower ACL injury rate in hops and had a
players; mean age, 19.9 y practices (P = .01), a lower late-season ACL injury tibial and fibular
rate (P = .03), a lower rate of noncontact ACL injuries fracture, after
in those who reported a history of ACL injury (P = which the cone
.05), and there was no difference between groups in height used was
the injury rates during games (P = .62), early in the adjusted to be
season (P = .93), or among those with no history of shorter
prior ACL injury (P = .43)
Table continues on page A20.
journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a19
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
Program Link
Achenbach et al1 https://www.ncbi.nlm.nih.gov/pubmed/29058022
https://doi.org/10.1007/s00167-017-4758-5
J Orthop Sports Phys Ther 2018.48:A1-A42.
a20 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
Program Link
11+* http://fifamedicinediploma.com/lessons/prevention-fifa-11/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3867089/
Emery and Meeuwisse14* https://www.ncbi.nlm.nih.gov/pubmed/20547668
http://bjsm.bmj.com/content/44/8/555.abstract
Goodall et al20* https://www.ncbi.nlm.nih.gov/pubmed/22924758
http://dx.doi.org/10.1080/17457300.2012.717085
Heidt et al27* https://www.ncbi.nlm.nih.gov/pubmed/11032220
http://ajs.sagepub.com/content/28/5/659.abstract
Junge et al34* https://www.ncbi.nlm.nih.gov/pubmed/12238997
http://ajs.sagepub.com/content/30/5/652.abstract
LaBella et al37* https://www.ncbi.nlm.nih.gov/pubmed/18832542
http://cpj.sagepub.com/content/48/3/327.long
Malliou et al41* https://www.ncbi.nlm.nih.gov/pubmed/15446640
http://journals.sagepub.com/doi/abs/10.2466/pms.99.1.149-154
Pasanen et al51* https://www.ncbi.nlm.nih.gov/pubmed/18595903
http://www.bmj.com/content/337/bmj.a295
Petersen et al52* https://www.ncbi.nlm.nih.gov/pubmed/23189409
Söderman et al60* https://www.ncbi.nlm.nih.gov/pubmed/11147154
Downloaded from www.jospt.org by 140.213.58.240 on 12/16/18. For personal use only.
https://link.springer.com/article/10.1007%2Fs001670000147
Wedderkopp et al78* https://www.ncbi.nlm.nih.gov/pubmed/9974196
https://onlinelibrary-wiley-com.e.bibl.liu.se/doi/pdf/10.1111/j.1600-0838.1999.tb00205.x
Abbreviations: CPG, clinical practice guideline; KLIP, Knee Ligament Injury Prevention; PEP, Prevent Injury and Enhance Performance.
*The individual studies of these programs did not meet the CPG inclusion criteria.
J Orthop Sports Phys Ther 2018.48:A1-A42.
journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a21
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
Department of Physical Therapy Department of Physical Therapy Department of Health and Exercise
Science Editor
University of Delaware University of Delaware
Beaver College of Health Sciences Academy of Orthopaedic Physical
Newark, DE Newark, DE
Appalachian State University Therapy, APTA, Inc
aohunter@udel.edu smack@udel.edu
Boone, NC La Crosse, WI
Tim Hewett, PhD howardjs@appstate.edu and
Director of Biomechanics and Sports REVIEWERS Professor
Medicine Research Roy D. Altman, MD David Killoran, PhD Physical Therapy Department
Mayo Sports Medicine Center Professor of Medicine Patient/Consumer Representative Marquette University
Departments of Orthopedics, Physical Division of Rheumatology and ICF-Based Clinical Practice Guidelines Milwaukee, WI
Medicine and Rehabilitation, Immunology Academy of Orthopaedic Physical guy.simoneau@marquette.edu
and Physiology and Biomedical David Geffen School of Medicine Therapy, APTA, Inc
University of California at Los Angeles La Crosse, WI Joseph J. Godges, DPT, MA
Engineering
Los Angeles, CA and ICF-Based Clinical Practice Guidelines
The Mayo Clinic
J Orthop Sports Phys Ther 2018.48:A1-A42.
ACKNOWLEDGMENTS: The authors acknowledge the contributions of George Washington University Himmelfarb Health Science librar-
ian Tom Harrod for his guidance and assistance in the design and implementation of the literature search; Nicholas Ienni and Sarah
Aoyama, Doctor of Physical Therapy students at George Washington University, for screening articles; Dean Caswell, PT, ATC, AT/L,
China Football Academy and Olympic Football Club of Beijing Sport University; Michael Lau, DPT, Co-Founder of The Prehab Guys,
Joe Godges, DPT, MA, University of Southern California, and Maury Hayashida, DPT, Motus Enterprises, LLC for their assistance in
creating the videos; Casson Demmon from The Make Studio for video production; and Demetri Dimitriadis, DPT, Talaria Physical
Therapy and Wellness, Christian Hintz, DPT, Fairview - Institute for Athletic Medicine, Kelli Baggett, DPT, University of Illinois Chicago
for their assistance in creating the "Contents of Programs Frequently Referenced in the CPG" Table.
a22 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
24. G
rindstaff TL, Hammill RR, Tuzson AE, Hertel J. Neuromuscular control
mss.0b013e31812f56d1
training programs and noncontact anterior cruciate ligament injury rates
9. D
onnell-Fink LA, Klara K, Collins JE, et al. Effectiveness of knee injury in female athletes: a numbers-needed-to-treat analysis. J Athl Train.
and anterior cruciate ligament tear prevention programs: a meta- 2006;41:450-456.
analysis. PLoS One. 2015;10:e0144063. https://doi.org/10.1371/journal.
25. G
rooms DR, Palmer T, Onate JA, Myer GD, Grindstaff T. Soccer-
pone.0144063
specific warm-up and lower extremity injury rates in collegiate
10. D
onnelly CJ, Elliott BC, Doyle TL, Finch CF, Dempsey AR, Lloyd DG. Chang- male soccer players. J Athl Train. 2013;48:782-789. https://doi.
es in knee joint biomechanics following balance and technique training org/10.4085/1062-6050-48.4.08
and a season of Australian football. Br J Sports Med. 2012;46:917-922.
26. H
ägglund M, Atroshi I, Wagner P, Waldén M. Superior compliance with a
https://doi.org/10.1136/bjsports-2011-090829
neuromuscular training programme is associated with fewer ACL injuries
11. D
rummond MF, Jefferson TO. Guidelines for authors and peer reviewers of and fewer acute knee injuries in female adolescent football players: sec-
economic submissions to the BMJ. BMJ. 1996;313:275-283. https://doi. ondary analysis of an RCT. Br J Sports Med. 2013;47:974-979. https://doi.
org/10.1136/bmj.313.7052.275 org/10.1136/bjsports-2013-092644
12. D
rummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. 27. H
eidt RS, Jr., Sweeterman LM, Carlonas RL, Traub JA, Tekulve FX. Avoid-
Methods for the Economic Evaluation of Health Care Programmes. 4th ed. ance of soccer injuries with preseason conditioning. Am J Sports Med.
Oxford, UK: Oxford University Press; 2015. 2000;28:659-662. https://doi.org/10.1177/03635465000280050601
13. E kstrand J, Gillquist J, Liljedahl SO. Prevention of soccer injuries. Supervi- 28. H
ewett TE, Ford KR, Myer GD. Anterior cruciate ligament injuries in female
sion by doctor and physiotherapist. Am J Sports Med. 1983;11:116-120. athletes: part 2, a meta-analysis of neuromuscular interventions aimed
https://doi.org/10.1177/036354658301100302 at injury prevention. Am J Sports Med. 2006;34:490-498. https://doi.
14. E mery CA, Meeuwisse WH. The effectiveness of a neuromuscular preven- org/10.1177/0363546505282619
tion strategy to reduce injuries in youth soccer: a cluster-randomised con- 29. H
ewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of neuro-
trolled trial. Br J Sports Med. 2010;44:555-562. https://doi.org/10.1136/ muscular training on the incidence of knee injury in female athletes. A
bjsm.2010.074377 prospective study. Am J Sports Med. 1999;27:699-706. https://doi.org/10.
1177/03635465990270060301
15. E ngebretsen AH, Myklebust G, Holme I, Engebretsen L, Bahr R. Preven-
tion of injuries among male soccer players: a prospective, random- 30. Hewett TE, Myer GD. Reducing knee and anterior cruciate ligament
journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a23
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
36. L aBella CR, Huxford MR, Grissom J, Kim KY, Peng J, Christoffel KK. Effect 51. P
asanen K, Parkkari J, Pasanen M, et al. Neuromuscular training and the
of neuromuscular warm-up on injuries in female soccer and basketball risk of leg injuries in female floorball players: cluster randomised con-
athletes in urban public high schools: cluster randomized controlled trial. trolled study. BMJ. 2008;337:a295. https://doi.org/10.1136/bmj.a295
Arch Pediatr Adolesc Med. 2011;165:1033-1040. https://doi.org/10.1001/
archpediatrics.2011.168 52. P
etersen W, Braun C, Bock W, et al. A controlled prospective case control
study of a prevention training program in female team handball players:
37. L aBella CR, Huxford MR, Smith TL, Cartland J. Preseason neuromus- the German experience. Arch Orthop Trauma Surg. 2005;125:614-621.
cular exercise program reduces sports-related knee pain in female https://doi.org/10.1007/s00402-005-0793-7
adolescent athletes. Clin Pediatr (Phila). 2009;48:327-330. https://doi.
org/10.1177/0009922808323903 53. P
etersen W, Zantop T, Steensen M, Hypa A, Wessolowski T, Hassenpflug
J. [Prevention of lower extremity injuries in handball: initial results of the
38. L ewis DA, Kirkbride B, Vertullo CJ, Gordon L, Comans TA. Comparison of Handball Injuries Prevention Programme]. Sportverletz Sportschaden.
four alternative national universal anterior cruciate ligament injury preven- 2002;16:122-126. https://doi.org/10.1055/s-2002-34753
tion programme implementation strategies to reduce secondary future
J Orthop Sports Phys Ther 2018.48:A1-A42.
a24 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
61. S
oligard T, Myklebust G, Steffen K, et al. Comprehensive warm-up Prevention and screening programs for anterior cruciate ligament injuries
programme to prevent injuries in young female footballers: cluster ran- in young athletes: a cost-effectiveness analysis. J Bone Joint Surg Am.
domised controlled trial. BMJ. 2008;337:a2469. https://doi.org/10.1136/ 2014;96:705-711. https://doi.org/10.2106/JBJS.M.00560
bmj.a2469
72. T aylor JB, Waxman JP, Richter SJ, Shultz SJ. Evaluation of the effective-
62. S
oligard T, Nilstad A, Steffen K, et al. Compliance with a comprehensive ness of anterior cruciate ligament injury prevention programme training
warm-up programme to prevent injuries in youth football. Br J Sports components: a systematic review and meta-analysis. Br J Sports Med.
Med. 2010;44:787-793. https://doi.org/10.1136/bjsm.2009.070672 2015;49:79-87. https://doi.org/10.1136/bjsports-2013-092358
63. S
teffen K, Myklebust G, Olsen OE, Holme I, Bahr R. Preventing in- 73. v an Beijsterveldt AM, Krist MR, Schmikli SL, et al. Effectiveness and cost-
juries in female youth football – a cluster-randomized controlled effectiveness of an injury prevention programme for adult male amateur
trial. Scand J Med Sci Sports. 2008;18:605-614. https://doi. soccer players: design of a cluster-randomised controlled trial. Inj Prev.
org/10.1111/j.1600-0838.2007.00703.x 2011;17:e2. https://doi.org/10.1136/ip.2010.027979
64. S
tevenson JH, Beattie CS, Schwartz JB, Busconi BD. Assessing the 74. v an Beijsterveldt AM, van de Port IG, Krist MR, et al. Effectiveness of an
effectiveness of neuromuscular training programs in reducing the injury prevention programme for adult male amateur soccer players: a
incidence of anterior cruciate ligament injuries in female athletes: a cluster-randomised controlled trial. Br J Sports Med. 2012;46:1114-1118.
systematic review. Am J Sports Med. 2015;43:482-490. https://doi. https://doi.org/10.1136/bjsports-2012-091277
org/10.1177/0363546514523388 75. V
erhagen AP, de Vet HC, de Bie RA, et al. The Delphi list: a criteria list for
65. S
tojanovic MD, Ostojic SM. Preventing ACL injuries in team-sport ath- quality assessment of randomized clinical trials for conducting systematic
letes: a systematic review of training interventions. Res Sports Med. reviews developed by Delphi consensus. J Clin Epidemiol. 1998;51:1235-
2012;20:223-238. https://doi.org/10.1080/15438627.2012.680988 1241. https://doi.org/10.1016/S0895-4356(98)00131-0
66. S
ugimoto D, Myer GD, Barber Foss KD, Hewett TE. Dosage effects of 76. V
escovi JD, VanHeest JL. Effects of an anterior cruciate ligament
neuromuscular training intervention to reduce anterior cruciate ligament injury prevention program on performance in adolescent female soc-
injuries in female athletes: meta- and sub-group analyses. Sports Med. cer players. Scand J Med Sci Sports. 2010;20:394-402. https://doi.
2014;44:551-562. https://doi.org/10.1007/s40279-013-0135-9 org/10.1111/j.1600-0838.2009.00963.x
Downloaded from www.jospt.org by 140.213.58.240 on 12/16/18. For personal use only.
67. S
ugimoto D, Myer GD, Barber Foss KD, Hewett TE. Specific exercise effects 77. W
aldén M, Atroshi I, Magnusson H, Wagner P, Hägglund M. Prevention
of preventive neuromuscular training intervention on anterior cruciate liga- of acute knee injuries in adolescent female football players: cluster ran-
ment injury risk reduction in young females: meta-analysis and subgroup domised controlled trial. BMJ. 2012;344:e3042. https://doi.org/10.1136/
analysis. Br J Sports Med. 2015;49:282-289. https://doi.org/10.1136/ bmj.e3042
bjsports-2014-093461 78. W
edderkopp N, Kaltoft M, Lundgaard B, Rosendahl M, Froberg K. Preven-
68. S
ugimoto D, Myer GD, Barber Foss KD, Pepin MJ, Micheli LJ, Hewett TE. tion of injuries in young female players in European team handball. A pro-
Critical components of neuromuscular training to reduce ACL injury spective intervention study. Scand J Med Sci Sports. 1999;9:41-47. https://
risk in female athletes: meta-regression analysis. Br J Sports Med. doi.org/10.1111/j.1600-0838.1999.tb00205.x
2016;50:1259-1266. https://doi.org/10.1136/bjsports-2015-095596 79. W
orld Health Organization. International Classification of Functioning, Dis-
69. S
ugimoto D, Myer GD, Bush HM, Klugman MF, Medina McKeon JM, Hewett ability and Health: ICF. Geneva, Switzerland: World Health Organization;
TE. Compliance with neuromuscular training and anterior cruciate liga- 2009.
J Orthop Sports Phys Ther 2018.48:A1-A42.
ment injury risk reduction in female athletes: a meta-analysis. J Athl Train. 80. Y oo JH, Lim BO, Ha M, et al. A meta-analysis of the effect of neuromus-
2012;47:714-723. https://doi.org/10.4085/1062-6050-47.6.10 cular training on the prevention of the anterior cruciate ligament injury in
70. S
ugimoto D, Myer GD, McKeon JM, Hewett TE. Evaluation of the effective- female athletes. Knee Surg Sports Traumatol Arthrosc. 2010;18:824-830.
ness of neuromuscular training to reduce anterior cruciate ligament injury https://doi.org/10.1007/s00167-009-0901-2
in female athletes: a critical review of relative risk reduction and numbers-
needed-to-treat analyses. Br J Sports Med. 2012;46:979-988. https://doi.
@ MORE INFORMATION
org/10.1136/bjsports-2011-090895
71. Swart E, Redler L, Fabricant PD, Mandelbaum BR, Ahmad CS, Wang YC. WWW.JOSPT.ORG
journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a25
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX A
PubMed
Search Strategy Search Limits
(Sports [MeSH] OR Athletes [MeSH] OR Exercise [MeSH] OR English only, then Clinical Trial, Clinical Trial Phase I, Clinical Trial
Athletic Injuries [MeSH]) AND ((Knee Injuries [MeSH]) OR Phase II, Clinical Trial Phase III, Clinical Trial Phase IV, Comparative
((Wounds and Injuries [MeSH] OR injur* [TW]) AND (ACL Study, Controlled Clinical Trial, Evaluation Studies, Guideline, Intro-
[TW] OR Anterior Cruciate Ligament* [TW] OR Anterior ductory Journal Article, Journal Article, Meta-Analysis, Multicenter
Cruciate Ligament [MeSH]))) AND (Risk Reduction Behav- Study, Observational Study, Practice Guideline, Pragmatic Clinical
ior [MeSH] OR Prevent* [TW] OR Predict* [TW]) Trial, Randomized Control Trial, Systematic Reviews, Twin Study
Scopus
Search Strategy Search Limits
(TITLE-ABS-KEY (Sport*) OR TITLE-ABS-KEY (Athlet*) OR TITLE-ABS-KEY English only, limit to Article, Review, and Article in Press
(Exercise) OR TITLE-ABS-KEY (Athletic Injur*)) AND ((TITLE-ABS-KEY
(Knee Injur*)) OR ((TITLE-ABS-KEY(Wound*) OR TITLE-ABS-KEY
(Injur*)) AND (TITLE-ABS-KEY (Anterior Cruciate Ligament) OR TITLE-
ABS-KEY (ACL)))) AND (TITLE-ABS-KEY (Risk Reduction) OR TITLE-
ABS-KEY (Prevent*) OR TITLE-ABS-KEY (Predict*))
Downloaded from www.jospt.org by 140.213.58.240 on 12/16/18. For personal use only.
SPORTDiscus
Search Strategy Search Limits
((TI (Sport*) OR AB (Sport*) OR (DE “Sports”)) OR (TI (Athlet*) OR AB English, English Abstract Only, Peer-Reviewed, Academic
(Athlet*) OR (DE “ATHLETICS”)) OR (TI (Exercise) OR AB (Exercise) Journal
OR (DE “EXERCISE”)) OR (TI (Athletic Injur*) OR AB (Athletic Injur*)))
AND ((TI (Knee Injur*) OR AB (Knee Injur*)) OR ((((TI (Wound*) OR AB
(Wound*)) OR (TI (Injur*) OR AB (Injur*))) OR (DE “WOUNDS & inju-
ries”)) AND ((TI (Anterior Cruciate Ligament) OR AB (Anterior Cruciate
Ligament) OR (DE “ANTERIOR cruciate ligament”)) OR (TI (ACL) OR
J Orthop Sports Phys Ther 2018.48:A1-A42.
CINAHL
Search Strategy Search Limits
((TI (Sport*) OR AB (Sport*) OR (MH “Sports+”)) OR (TI (Athlet*) OR English Language checkbox, Adolescent, Adult, Middle-
AB (Athlet*)) OR (TI (Exercise) OR AB (Exercise) OR (MH “Exercise+”)) Aged, Aged 65+. Aged 80+, Clinical Trial, Corrected
OR (TI (Athletic Injur*) OR AB (Athletic Injur*) OR (MH “Athletic Inju- Article, Journal Article, Practice Guidelines, Research,
ries+”))) AND ((TI (Knee Injur*) OR AB (Knee Injur*) OR (MH “Knee Systematic Review
Injuries+”)) OR ((TI (Wound*) OR AB (Wound*) OR TI (Injur*) OR AB
(Injur*) OR (MH “Wounds and Injuries+”)) AND (TI (Anterior Cruciate
Ligament) OR AB (Anterior Cruciate Ligament) OR TI (ACL) OR AB
(ACL) OR (MH “Anterior Cruciate Ligament+”)))) AND ((TI (Risk Reduc-
tion) OR AB (Risk Reduction)) OR (TI (Prevent*) OR AB (Prevent*)) OR
(TI (Predict*) OR AB (Predict*)))
Cochrane
Search Strategy Search Limits
((Sport*) OR (Athlet*) OR (Exercise) OR (Athletic Injur*)) AND (((Knee Cochrane Reviews - ALL, Other Reviews, Trials, Technology
Injur*)) OR (((Wound*) OR ( Injur*)) AND ((Anterior Cruciate Ligament) Assessments, Economic Evaluations
OR (ACL)))) AND ((Risk Reduction) OR (Prevent*) OR (Predict*))
a26 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX B
Initial Search
Database Date Conducted Results, n
PubMed 3/31/2015 812
Scopus 3/31/2015 2083
SPORTDiscus 3/31/2015 511
CINAHL 3/31/2015 275
Cochrane Library 3/31/2015 145
Cochrane reviews 6
Other reviews 12
Trials 126
Technology assessments 0
Economic evaluations 1
Total 3826
Total with duplicates removed 2623
Downloaded from www.jospt.org by 140.213.58.240 on 12/16/18. For personal use only.
Trials 12
Technology assessments 0
Economic evaluations 0
Total 482
Total with duplicates removed 341
journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a27
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX C
• Not meta-analysis/systematic
review/cohort study, n = 3
• Article not on prevention, n = 24
• Risk factors for knee injury, n = 1
Articles meeting inclusion/exclusion criteria,
n = 42
Included articles, n = 33
a28 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX D
https://doi.org/10.1371/journal.pone.0144063
in female athletes in different sports: a systematic review.
Gagnier JJ, Morgenstern H, Chess L. Interventions designed Phys Ther Sport. 2014;15:200-210. https://doi.org/10.1016/j.
to prevent anterior cruciate ligament injuries in adoles- ptsp.2013.12.002
cents and adults: a systematic review and meta-analysis.
Myer GD, Ford KR, Brent JL, Hewett TE. Differential neuromuscu-
Am J Sports Med. 2013;41:1952-1962. https://doi.
lar training effects on ACL injury risk factors in “high-risk” ver-
org/10.1177/0363546512458227
sus “low-risk” athletes. BMC Musculoskelet Disord. 2007;8:39.
Gilchrist J, Mandelbaum BR, Melancon H, et al. A random- https://doi.org/10.1186/1471-2474-8-39
ized controlled trial to prevent noncontact anterior
cruciate ligament injury in female collegiate soccer play- Myer GD, Sugimoto D, Thomas S, Hewett TE. The influence of
ers. Am J Sports Med. 2008;36:1476-1483. https://doi. age on the effectiveness of neuromuscular training to reduce
org/10.1177/0363546508318188 anterior cruciate ligament injury in female athletes: a meta-
J Orthop Sports Phys Ther 2018.48:A1-A42.
journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a29
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX D
Stevenson JH, Beattie CS, Schwartz JB, Busconi BD. Assess- cruciate ligament injury in female athletes: a critical review of
ing the effectiveness of neuromuscular training programs in relative risk reduction and numbers-needed-to-treat analyses.
reducing the incidence of anterior cruciate ligament injuries Br J Sports Med. 2012;46:979-988. https://doi.org/10.1136/
in female athletes: a systematic review. Am J Sports Med. bjsports-2011-090895
2015;43:482-490. https://doi.org/10.1177/0363546514523388 Swart E, Redler L, Fabricant PD, Mandelbaum BR, Ahmad CS,
Sugimoto D, Myer GD, Barber Foss KD, Hewett TE. Dosage effects Wang YC. Prevention and screening programs for anterior cru-
of neuromuscular training intervention to reduce anterior ciate ligament injuries in young athletes: a cost-effectiveness
cruciate ligament injuries in female athletes: meta- and sub- analysis. J Bone Joint Surg Am. 2014;96:705-711. https://doi.
group analyses. Sports Med. 2014;44:551-562. https://doi. org/10.2106/JBJS.M.00560
org/10.1007/s40279-013-0135-9 Taylor JB, Waxman JP, Richter SJ, Shultz SJ. Evaluation of the
Sugimoto D, Myer GD, Barber Foss KD, Hewett TE. Specific effectiveness of anterior cruciate ligament injury prevention
exercise effects of preventive neuromuscular training inter- programme training components: a systematic review and
vention on anterior cruciate ligament injury risk reduction meta-analysis. Br J Sports Med. 2015;49:79-87. https://doi.
in young females: meta-analysis and subgroup analysis. Br org/10.1136/bjsports-2013-092358
J Sports Med. 2015;49:282-289. https://doi.org/10.1136/ van Beijsterveldt AM, Krist MR, Schmikli SL, et al. Effectiveness
bjsports-2014-093461 and cost-effectiveness of an injury prevention programme
Sugimoto D, Myer GD, Barber Foss KD, Pepin MJ, Micheli LJ, for adult male amateur soccer players: design of a cluster-
Hewett TE. Critical components of neuromuscular training randomised controlled trial. Inj Prev. 2011;17:e2. https://doi.
Downloaded from www.jospt.org by 140.213.58.240 on 12/16/18. For personal use only.
a30 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX E
QUALITY-ASSESSMENT SCORES
Sugimoto et al70 x x x x x x x x x 9
Taylor et al72 x x x x x x x x 8
Yoo et al80 x x x x x 5
Abbreviation: AMSTAR, A Measurement Tool to Assess Systematic Reviews.
*Yes/no. Items: 1, Was an a priori design provided? 2, Was there duplicate study selection and data extraction? 3, Was a comprehensive literature search per-
formed? 4, Was the status of publication (ie, gray literature) used as an inclusion criterion? 5, Was a list of studies (included and excluded) provided? 6, Were
the characteristics of the included studies provided? 7, Was the scientific quality of the included studies assessed and documented? 8, Was the scientific quality
of the included studies used appropriately in formulating conclusions? 9, Were the methods used to combine the findings of studies appropriate? 10, Was the
likelihood of publication bias assessed? 11, Was the conflict of interest included?
†
What is your overall assessment of the methodological quality of this review? High quality, 8 or greater; acceptable, 5, 6, or 7; reject, 4 or less.
journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a31
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX E
Caraffa et al5 x x x x x x x x x 9
Hewett et al29 x x x x x 5
Kiani et al35 x x x x x x x x x x x 11
LaBella et al37 x x x x 4
Mandelbaum et al42 x x x x x x x x 8
Myer et al44 x x x x x 5
Myklebust et al46 x x x x x x x 7
Pfeiffer et al54 x x x x x x 6
*Items: 1, The study addresses an appropriate and clearly focused question; 2, The 2 groups being studied are selected from source populations that are com-
J Orthop Sports Phys Ther 2018.48:A1-A42.
parable in all respects other than the factor under investigation; 3, The study indicates how many of the people asked to take part did so, in each of the groups
being studied; 4, The likelihood that some eligible subjects might have the outcome at the time of enrollment is assessed and taken into account in the analysis;
5, What percentage of individuals or clusters recruited into each arm of the study dropped out before the study was completed? 6, Comparison is made between
full participants and those lost to follow-up, by exposure status; 7, The outcomes are clearly defined; 8, The assessment of outcome is made blind to exposure
status (if the study is retrospective, this may not be applicable); 9, Where blinding was not possible, there is some recognition that knowledge of exposure status
could have influenced the assessment of outcome; 10, The method of assessment of exposure is reliable; 11, Evidence from other sources is used to demonstrate
that the method of outcome assessment is valid and reliable; 12, Exposure level or prognostic factor is assessed more than once; 13, The main potential con-
founders are identified and taken into account in the design and analysis; 14, Have confidence intervals been provided?
†
How well was the study done to minimize the risk of bias or confounding? Quality rating: 8 or higher, high; 5, 6, or 7, acceptable; 4 or less, reject.
a32 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX E
Where market values were absent, or market values did not reflect actual values, were adjustments x
made to approximate market values?
Was the valuation of consequences appropriate for the question posed? x x
Were costs and consequences adjusted for differential timing?
Were costs and consequences that occur in the future “discounted” to their present values? x
Was any justification given for the discounted rate used? x
Was an incremental analysis of costs and consequences of alternatives performed?
Were the additional costs generated by one alternative over another compared to the additional effects, x
benefits, or utilities generated?
Was allowance made for uncertainty in the estimates of cost and consequences?
J Orthop Sports Phys Ther 2018.48:A1-A42.
If patient-level data on costs or consequences were available, were appropriate statistical analyses x x
performed?
If a sensitivity analysis was employed, was justification provided for the ranges or distributions of val- x x
ues, and the form of sensitivity analysis used?
Were the conclusions of the study sensitive to the uncertainty in the results, as quantified by the statis- x x
tical and/or sensitivity analysis?
Did the presentation and discussion of study results include all issues of concern to users?
Were the conclusions of the analysis based on some overall index or ratio of costs to consequences? If x x
so, was the index interpreted intelligently or in a mechanistic fashion?
Were the results compared with those of others who have investigated the same question? If so, were
allowances made for potential differences in study methodology?
Did the study discuss the generalizability of the results to other settings and patient/client groups? x
Did the study allude to, or take account of, other important factors in the choice or decision under x x
consideration?
Did the study discuss issues of implementation, such as feasibility of adopting the “preferred” program x x
given existing financial or other constraints, and whether any freed resources could be redeployed to
other worthwhile programs?
Quality score 21 20
*Only studies that met inclusion/exclusion criteria were reviewed for quality. There are studies referred to in this clinical practice guideline that did not meet
the inclusion/exclusion criteria themselves but receive mention because they are included in systematic reviews or meta-analyses that did meet the inclusion/
exclusion criteria, for example, Söderman et al.60
journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a33
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX F
ecological study
III Systematic reviews of Lower-quality retro- Lower-quality explor- Local nonrandom study High-quality cross-
case-control studies spective cohort study atory diagnostic sectional study
High-quality case- High-quality cross- studies
control study sectional study Nonconsecutive retro-
Lower-quality cohort Case-control study spective cohort
study
IV Case series Case series Case-control study … Lower-quality cross-
sectional study
V Expert opinion Expert opinion Expert opinion Expert opinion Expert opinion
J Orthop Sports Phys Ther 2018.48:A1-A42.
a34 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX G
PROCEDURES USED FOR ASSIGNING • Cohort study includes greater than 80% follow-up
LEVELS OF EVIDENCE • Diagnostic study includes consistently applied reference
• Level of evidence is assigned based on the study design using standard and blinding
the Levels of Evidence table (APPENDIX F), assuming high quality • Prevalence study is a cross-sectional study that uses a lo-
(eg, for intervention, randomized clinical trial starts at level I) cal and current random sample or censuses
- Acceptable quality (the study does not meet requirements
• Study quality is assessed using the critical appraisal tool, and
for high quality and weaknesses limit the confidence in the
the study is assigned 1 of 4 overall quality ratings based on the
accuracy of the estimate): downgrade 1 level
critical appraisal results
• Based on critical appraisal results
• Level of evidence assignment is adjusted based on the overall - Low quality: the study has significant limitations that sub-
quality rating: stantially limit confidence in the estimate: downgrade 2
- High quality (high confidence in the estimate/results): study levels
remains at assigned level of evidence (eg, if the randomized • Based on critical appraisal results
clinical trial is rated high quality, its final assignment is level - Unacceptable quality: serious limitations—exclude from con-
I). High quality should include: sideration in the guideline
• Randomized clinical trial with greater than 80% follow-up, • Based on critical appraisal results
blinding, and appropriate randomization procedures
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journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a35
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX H
Tertiary: pooled incidence rate ratio for noncontact ACL injuries = 0.51
(95% CI: 0.30, 0.88)
Gagnier et al18
Caraffa et al,5 Ettlinger et al,16 Primary: overall ACL Primary: pooled incidence rate ratio = 0.49 (95% CI: 0.30, 0.79; P<.01),
Gilchrist et al,19 Heidt et al,27 injury incidence with some effects of heterogeneity
Hewett et al,29 Kiani et al,35 Secondary: subgroup Secondary subgroup analysis: pooled incidence rate ratio smaller (stron-
Mandelbaum et al,42 Mykle- analysis of ACL in- ger inverse association) for nonrandomized cohort studies (pooled
bust et al,46 Olsen et al,49 jury incidence incidence rate ratio = 0.38; 95% CI: 0.20, 0.70; P<.01), studies in the
Pasanen et al,51 Petersen et United States (pooled incidence rate ratio = 0.36; 95% CI: 0.15, 0.88; P
al,52 Pfeiffer et al,54 Söder- = .03), studies of longer duration (>14 mo) (pooled incidence rate ratio
J Orthop Sports Phys Ther 2018.48:A1-A42.
man et al,60 Steffen et al63 = 0.41; 95% CI: 0.20, 0.84; P = .01), studies with more hours of training
per week (>0.75 h) (pooled incidence rate ratio = 0.38; 95% CI: 0.18,
0.77; P<.01), studies that reported better compliance (>64%) (pooled
incidence rate ratio = 0.39; 95% CI: 0.17, 0.89; P = .03), studies that
reported no dropouts (pooled incidence rate ratio = 0.30; 95% CI: 0.15,
0.62; P<.01), and studies that included only soccer players (pooled
incidence rate ratio = 0.30; 95% CI: 0.16, 0.56; P<.01). Little difference,
though significant, for females (pooled incidence rate ratio = 0.51; 95%
CI: 0.28, 0.94; P = .03). No significant difference between those inter-
ventions that included plyometric exercises compared to those that did
not (no P value presented)
Sadoghi et al57
Caraffa et al,5 Gilchrist et al,19 Risk of ACL injury Risk differences reported in the component studies varied considerably
Heidt et al,27 Hewett et al,29 Numbers needed to treat ranged from 5 to 187
Mandelbaum et al,42 Peters- One study had a lower risk in controls
en et al,52 Petersen et al,53 Pooled risk ratio was 0.38 (95% CI: 0.20, 0.72; P<.01), indicating a signifi-
Pfeiffer et al,54 Söderman et cant decrease in risk in the intervention groups
al,60 Myklebust et al46 Stratified by sex: pooled risk ratio for women = 0.48 (95% CI: 0.26, 0.89;
P = .02) and for men = 0.15 (95% CI: 0.08, 0.28; P<.01)
Use of a balance board or video assistance, the duration of follow-up, or
year of publication did not affect the pooled risk ratio
Conducting the intervention during the preseason, compared to during the
playing season, reduced the risk by 19.1%, but this was not significant
Abbreviations: ACL, anterior cruciate ligament; CI, confidence interval.
a36 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX I
EFFICACY OF EXERCISE-BASED KNEE INJURY PREVENTION PROGRAMS IN MALE AND FEMALE PARTICIPANTS
Sex/Review/Included Articles Outcomes Examined Findings
Male
Alentorn-Geli et al2
Bencke et al,3 Caraffa et Reduction of ACL Two of 7 studies examined the effect of interventions on ACL injury rates: 1 found a
al,5 Cochrane et al,7 injury significant reduction in ACL injury rates,5 1 had no ACL injuries in either group (but
Dempsey et al,8 Don- did have a 72% decrease in lower extremity injury risk)25
nelly et al,10 Grooms et The quality of studies increased over time
al,25 Jamison et al33
Female
Grimm et al23
Brushøj et al,4 Ekstrand Knee and ACL injury Two of 10 studies showed a reduction in knee injuries13,49
et al,13 Emery incidence Four studies reported a nonsignificant increase in knee injuries in the intervention
and Meeuwisse,14 group14,15,19,61
Engebretsen et al,15 Two of 3 studies examining ACL injury incidence found decreases in number of inju-
Gilchrist et al,19 Olsen et ries, but none found a significant reduction19,49,60
al,49 Söderman et al,60 One study showed a nonsignificant increase in ACL injuries in the intervention
Soligard et al,61 Steffen et group60
al,63 Wedderkopp et al78 No evidence of publication bias
Downloaded from www.jospt.org by 140.213.58.240 on 12/16/18. For personal use only.
Myer et al45
Gilchrist et al,19 Heidt et ACL injury incidence Overall, a significantly greater knee injury reduction in female athletes in intervention
al,27 Hewett et al,29 Kiani based on age groups compared to controls (odds ratio = 0.54; 95% CI: 0.35, 0.83)
et al,35 LaBella et al,36 Age dichotomized: under 18 y (odds ratio = 0.28; 95% CI: 0.18, 0.42; P<.01) and over
Mandelbaum et al,42 18 y (odds ratio = 0.84; 95% CI: 0.56, 1.26; P = .39)
Myklebust et al,46 Olsen Age in tertiles: those aged 14-18 y had an odds ratio of 0.28 (95% CI: 0.18, 0.42;
et al,49 Pasanen et al,51 P<.01), those aged 18-20 y had an odds ratio of 0.48 (95% CI: 0.21, 1.07; P = .07),
Petersen et al,52 Pfeiffer and those aged >20 y had an odds ratio of 1.01 (95% CI: 0.62, 1.64; P = .97)
et al,54 Söderman et al,60 No evidence of publication bias
Steffen et al,63 Waldén
et al77
J Orthop Sports Phys Ther 2018.48:A1-A42.
Stevenson et al64
Gilchrist et al,19 Heidt et ACL injury incidence Two of 10 programs achieved a statistically significant decrease in ACL injuries29,42
al,27 Hewett et al,29 Kiani One study had a significant decrease in the incidence of ACL injuries during prac-
et al,35 Mandelbaum et tices, late in the season, and in noncontact ACL injuries in those with a history of
al,42 Myklebust et al,46 prior ACL injuries19
Petersen et al,52 Pfeiffer Another study had a significant decrease in the ACL injury incidence in elite
et al,54 Söderman et al,60 athletes46
Steffen et al63 Two studies had significant decreases in the ACL injury rate among those who were
deemed compliant with the program46,63
One study had all noncontact ACL injuries in the control group, but no noncontact
ACL injuries in the intervention group52
One study had a significant increase in major knee injuries (80% of injuries in the
intervention group)60
One study had an increase in noncontact ACL injuries in the intervention group; however,
it did not reach statistical significance.54 When controlling for sport, this study had a
4-fold higher incidence of injuries in trained female basketball players than in control
players
Eight of the 10 studies included plyometric exercises19,27,29,42,46,52,54,63
All 4 studies reporting some statistically significant decrease in ACL injuries includ-
ed plyometrics, strength training, and flexibility19,29,42,46
Only 1 of the studies that included plyometrics failed to show a decrease in ACL
injuries54
The 1 study that only included a balance component to the training had an increase
in ACL injury incidence60
Table continues on page A38.
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Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX I
exercises reduced ACL injuries (odds ratio = 0.33; 95% CI: 0.23, 0.47; P<.01). Pro-
grams that did not include proximal control exercises (odds ratio = 0.95; 95% CI:
0.60, 1.50; P = .82) did not reduce ACL injuries
Sugimoto et al68
Gilchrist et al,19 Heidt et ACL injury incidence Critical components of exercise-based ACL injury prevention programs: based on
al,27 Hewett et al,29 Kiani the odds ratios of previous studies, age (14-18 y), dosage (>20 min per training
et al,35 LaBella et al,36 session), frequency (multiple times per week), and exercises (multiple exercise
Mandelbaum et al,42 components) were deemed necessary attributes of prevention programs
Myklebust et al,46 Olsen Using meta-regression, the authors found a 17% lower odds of an ACL injury if 1 of
et al,49 Pasanen et al,51 these 4 necessary components was included in a prevention program (odds ratio
Petersen et al,52 Pfeiffer = 0.83; β1 = –0.29; 95% CI: –0.33, –0.03; P = .03). This finding was similar when
J Orthop Sports Phys Ther 2018.48:A1-A42.
a38 | september 2018 | volume 48 | number 9 | journal of orthopaedic & sports physical therapy
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX I
Abbreviations: ACL, anterior cruciate ligament; AE, athlete-exposure; CI, confidence interval.
J Orthop Sports Phys Ther 2018.48:A1-A42.
journal of orthopaedic & sports physical therapy | volume 48 | number 9 | september 2018 | a39
Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX J
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Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX J
15- to 17-year-old team times per week, subluxation, rupture of the collateral
handball players; throughout the or cruciate ligament, meniscus tear,
male and female season) or cartilage injury that led to more
than 28 d of absence from sport),
0.04/1000 h
Control-group injury incidence,
0.33/1000 h; intervention group,
0.04/1000 h
Intervention led to a significant decrease
in severe knee injuries (odds ratio =
0.11; 95% CI: 0.01, 0.90; P = .02)
Myklebust Cohort Control season, n = 942 Throughout team Control-season ACL injury incidence, None
et al46 First intervention sea- handball season, 0.14/1000 playing hours; first-inter-
son, n = 855 including preseason vention-season ACL injury incidence,
Second intervention (15 min, 3 times per 0.13/1000 playing hours; second-
season, n = 850 week, during pre- intervention-season ACL injury inci-
Female Norwegian team season and once per dence, 0.06/1000 playing hours
handball league play- week during regular No significant difference in injury rate
ers; mean age not season) (odds ratio = 0.52; 95% CI: 0.15, 1.82;
provided P = .31)
When adjusted for compliance, there
was a significant decrease in odds of
injury in the elite division (odds ratio =
0.06; 95% CI: 0.01, 0.54; P = .01)
Table continues on page A42.
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Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention: Clinical Practice Guidelines
APPENDIX J
Pfeiffer Cohort Intervention, n = 191 Throughout high school Basketball control group, 0.111/1000 None
et al54 Control, n = 319 basketball season AEs; basketball intervention group,
Female high school– (20 min; the authors 0.476/1000 AEs
aged basketball did not report the
players recommended
number of times per
week)
Volleyball
Hewett Cohort Female intervention, n 6 wk during the pre- No serious knee injuries in any volleyball None
et al29 = 185 season (60-90 min, players in this study, thus unable to
Female control, n = 81 3 times per week) make any comparison
High school–aged vol-
leyball players
Pfeiffer Cohort Intervention, n = 197 Throughout high school No noncontact ACL injuries in any volley- None
et al54 Control, n = 299 volleyball season (20 ball players in this study, thus unable
Female high school– min; the authors did to make any comparison
aged volleyball not report the rec-
players ommended number
of times per week)
Abbreviations: ACL, anterior cruciate ligament; AE, athlete-exposure; CI, confidence interval; NCAA, National Collegiate Athletic Association; RCT, random-
ized controlled trial.
*Programs are organized by sport, and only the results related to the specific sport are presented in this table. Full results of each program are listed in TABLE 3.
†
Included studies: Ekstrand et al,13 Emery and Meeuwisse,14 Engebretsen et al,15 Gilchrist et al,19 Söderman et al,60 Soligard et al,61 Steffen et al,63 van Beijsterveldt
et al,74 Waldén et al.77
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